Medical Center Compliance Services Standards

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Principal Standards

The Jackson South Medical Center is committed to the principal standards of implementing CLAS in its operations. It has a Local Board of Health subcommittee on CLAS, which oversees its implementation. The central guideline in National culturally and linguistically appropriate services standards (n.d.) is also presented in the Jackson Health System’s Employee handbook (n.d.). The Center is a part of the System and follows its guidelines, which is reflected in its practices. To that end, every employee at the facility is committed to providing effective and equitable care to every patient with respect and attention to their specific needs. They work to maintain current practices and improve the quality of treatments that are distributed to the diverse patient population of the Center.

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Communication and Language

A majority of the Center’s staff speak English, but a substantial portion of the employees also speaks Spanish. Several workers are fluent in French and Chinese, and the facility tries to assign them to patients that predominantly speak these languages. Patient materials are available in all of these languages at the Center and distributed as is appropriate. With that said, there are numerous other minorities in Miami, and the facility struggles to meet the needs of patients from these groups when they come in. English is generally used as the mode of communication in that case, which usually does not create substantial difficulties.

Engagement and Continuous Improvement

The hospital does not actively engage with the community, though it strives to provide the highest standard of patient care. The primary reason is that it is specialized in acute care rather than community health, focusing on its inpatients. However, it actively works to improve the quality of the culturally appropriate care that it provides. To that end, it collects patient satisfaction data and suggestions for improvement while considering staff feedback. This data is then analyzed and used to identify deficiencies, after which the management and workers propose and implement improvement measures. As an example, the French and Chinese translations of the facility’s materials were reviewed recently and changed to improve the quality and cultural appropriateness of the translation.


The Center uses a variety of measures to evaluate the quality of the services that it currently provides to various ethnicities and communities, as well as the success of its improvements. Recently, the Center has updated its definition of culture to include sexual orientation and disability per the updated national CLAS guidelines (Nash et al., 2019). Internally, the Center also tries to make its hiring practices as transparent as possible and promote diversity to improve the quality of the care that it provides to various communities.


  1. There is a formal grievance procedure that patients can use to make their issues known and create change.
  2. Approximately 34,000 patients visit the Center’s emergency department every year (About Jackson South Medical Center, n.d.). As such, it is possible to assert that the population that is served is of approximately the same size.
  3. There is no formal quality improvement plan for culturally and linguistically diverse clients. Instead, the initiatives that aim to improve the care that they receive emerge sporadically and are considered and implemented independently of each other.
  4. The mission statement of the Center and the Jackson Health System as a whole is “To build the health of the community by providing a single, high standard of quality care for the residents of Miami-Dade County” (About Jackson Health System, n.d.). As is evident from the formulation, it does not address CLAS directly, though it is implied in the provision of a single standard of quality.
  5. The Center conducts bi-annual CLAS training seminars for its employees, where the latest knowledge on the topic is reviewed and supported with practical examples. All staff members are required to attend these seminars, which ensures that they learn about the latest developments in the field.
  6. The policy of the Jackson Health System recognizes the existence of different populations and promotes care that is specific to them (Employee handbook, n.d.).
  7. Specific staff members and materials will be assigned to patients depending on their culture and spoken languages. However, the treatments that are provided to patients are uniform, and all patients are treated using the same strategies.
  8. The Center regularly reviews its approach to patients from various cultures and their responses to these approaches. To that end, it surveys staff regarding their cultural competencies periodically and tries to collect feedback from patients.
  9. The Center has a diversity plan, the goal of which is to hire enough workers from various ethnicities to be able to provide culturally appropriate care to various patients consistently. The staff is still majority white, but the number of minority workers and employees that can speak different languages has been increasing recently.
  10. Overall, on a scale of 1 to 10, the author would rate their organization as a 7. Its commitment to CLAS is generally adequate for the population, but there are substantial improvement opportunities.


About Jackson Health System. (n.d.). Jackson Health System.

About Jackson South Medical Center. (n.d.). Jackson Health System.

The employee handbook: Welcome to our team of miracle-makers. (n.d.). Jackson Health System. Web.

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Nash, D. B., Skoufalos, A., Fabius, R. J., & Oglesby, W. H. (2019). Population health: Creating a culture of wellness (3rd ed.). Jones & Bartlett Learning.

National culturally and linguistically appropriate services standards. (n.d.). U.S. Department of Health & Human Services.

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NursingBird. (2022, January 12). Medical Center Compliance Services Standards. Retrieved from


NursingBird. (2022, January 12). Medical Center Compliance Services Standards.

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"Medical Center Compliance Services Standards." NursingBird, 12 Jan. 2022,


NursingBird. (2022) 'Medical Center Compliance Services Standards'. 12 January.


NursingBird. 2022. "Medical Center Compliance Services Standards." January 12, 2022.

1. NursingBird. "Medical Center Compliance Services Standards." January 12, 2022.


NursingBird. "Medical Center Compliance Services Standards." January 12, 2022.